MEDICARE: MATTHEW JAMES CARLOS EDMONDSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1528711199
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW JAMES CARLOS EDMONDSON

Provider Business Mailing Address
First Line	:	21600 OXNARD ST
Second Line	:
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91367-4976
Country	:	US
Telephone Number	:	818-345-2345
Fax Number	:

Provider Business Practice Location Address
First Line	:	4700 SPRING STREET
Second Line	:	STE. 180
City	:	SAN DIEGO
State	:	CA
Zip	:	91941
Country	:	US
Telephone Number	:	619-404-0839
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2022
Last Update Date	:	02/02/2022

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